Provider Demographics
NPI:1740816313
Name:SLAGLE, TRAVIS (LPC, LMHC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:SLAGLE
Suffix:
Gender:M
Credentials:LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 1 BOX 5230
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-9513
Mailing Address - Country:US
Mailing Address - Phone:541-930-2857
Mailing Address - Fax:
Practice Address - Street 1:15 KANOA ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2426
Practice Address - Country:US
Practice Address - Phone:808-895-6717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5150101YP2500X
HIMHC503101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty